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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WOROT <br /> �- <br /> FACILITY/SITE NAME FACILITY CONTACT NAME <br /> C Ripon Fire Department Gene Vanderplaats <br /> L STREET ADDRESS SITE PHONE 1 (with Area Code) <br /> 1 142 S. Stockton Avenue (209) 599-4209 <br /> T <br /> Y CITY STATE ZIP CODE t of TANK'S <br /> Ripon, CA 95336 at Site 1 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> F same <br /> L <br /> 1 MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION Tank Removal <br /> T (Closure, Installation, etc.) <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1988 1989 <br /> T 1 <br /> I <br /> V <br /> E TANK FEE = 150.00 each TANK <br /> F t Tanks x $50.00 1986 1981 1908 1989 <br /> A (multipTy-i-by,fee for 1 <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH f SAFETY CODE Sec 25281 for applicability) <br /> I <br /> T t Tanks x 156.00 1986 1981 1988 1989 <br /> Y (enter enount and year) 1 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L t Tanks x $90.00 S 90.00 <br /> 0 CLOSURE FEE _ $90.00 each TANK ___�. <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = 180.00 each TANK 1 Tanks_____ x (80.00 f <br /> P PLAN CHECK (Installation or Repaid <br /> I - <br /> A FF <br /> N PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> P. <br /> E TANK REPAIR FEE = 1110.00 each TANK 1 Tanks x 1110.00 f <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = 130.00lhr FEE = 135.00/hr FEE _ $35.00/hr f <br /> TOTAL DUE Is �( <br /> OFFICE USE ONLY <br /> SNEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK WASH RCVD BY DATE RECEIVED PERMIT t <br /> u • <br /> • <br />